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Dental Screening & Oral Health Check-In Survey

Captures a patient's oral hygiene habits, symptoms, and dental visit history ahead of or following a screening, for dental practices, insurers, or public health programs. The AI follow-up interview digs into any reported pain or concern to surface details a checklist alone would miss, helping clinicians triage and prioritize care.

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Sample questions

A preview of what’s in the template. Every question is editable before you launch.

15 questions · ~8 min
Q01
Message

Hi! Before your dental screening, we'd like to understand your oral health habits and any concerns you have. This takes about 8 minutes and helps your care team prepare for your visit.

Q02
Multiple ChoiceRequired

When was your last dental visit (checkup, cleaning, or treatment)?

  • Within the last 6 months
  • 6-12 months ago
  • 1-2 years ago
  • More than 2 years ago
  • I've never been to a dentist
Q03
Multiple ChoiceRequired

What is the main reason for this dental visit?

  • Routine checkup or cleaning
  • Specific pain or discomfort
  • A broken or chipped tooth
  • Follow-up on previous treatment
  • Cosmetic concern
Q04
MatrixRequired

In the last 3 months, how often have you experienced any of the following?

5 rows × 4 columns
  • Tooth pain or sensitivity
  • Bleeding or swollen gums
  • Bad breath
  • Jaw pain or clicking
  • Difficulty chewing
Columns: Never · Rarely · Sometimes · Often
Q05
Multiple ChoiceRequired

In the last week, how many times per day did you brush your teeth on average?

  • I didn't brush daily
  • Once a day
  • Twice a day
  • Three or more times a day
Q06
Multiple ChoiceRequired

In the last week, how often did you floss or use an interdental cleaner?

  • Never
  • 1-2 times
  • 3-5 times
  • Every day
Q07
Opinion ScaleRequired

Overall, how would you rate the current health of your teeth and gums?

Scale: 1 – 7
Min:Very poorMax:Excellent
Q08
Rating Scale

How anxious or uncomfortable do you typically feel about dental visits?

Range: 1 – 5
Min:Not at all anxiousMax:Extremely anxious
Q09
AI Interview

If the respondent reported any pain, sensitivity, bleeding, or jaw discomfort, probe for specifics: where exactly it's located, how long it's been happening, what triggers it (cold, chewing, brushing), and whether it's getting worse. If they reported high dental anxiety, gently explore what specifically makes visits stressful (past experience, needles, cost, loss of control) so the care team can adjust the visit. If no symptoms or anxiety were reported, ask a light confirmation question about their current oral care routine instead.

Q10
Multiple Choice

What, if anything, makes it hard for you to get dental care when you need it?

  • Cost or lack of insurance
  • Fear or anxiety about dental visits
  • Difficulty getting time off work or school
  • Trouble finding a nearby provider
  • Long wait times for appointments
Q11
Multiple Choice

Do you currently have dental insurance or a dental benefit plan?

  • Yes
  • No
  • Not sure
Q12
Message

Just a couple of quick background questions to finish up.

Q13
Multiple Choice

What is your age group?

  • Under 18
  • 18-24
  • 25-34
  • 35-44
  • 45-54
  • 55-64
  • 65 or older
  • Prefer not to say
Q14
Multiple Choice

What is your gender?

  • Woman
  • Man
  • Non-binary
  • Prefer to self-describe
  • Prefer not to say
Q15
Message

Thank you for sharing this with us! Your responses will be reviewed by your care team ahead of your screening so they can focus on what matters most to you.

What’s included

  • AI follow-ups

    Adaptive probes on open-ended answers that pull out detail a static form would miss.

  • Attention checks

    Built-in safeguards against rushed answers and low-quality respondents.

  • AI-drafted copy

    Wording, ordering, and branching written by the AI — tuned to your research goal.

  • Auto report

    Themes, quotes, and a plain-English summary write themselves once responses come in.

How it compares

We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.

Why this template

  • Goes beyond a static checklist with an AI follow-up interview that automatically digs deeper into any reported pain, sensitivity, bleeding, or jaw discomfort, surfacing detail a fixed form would miss.
  • Combines structured habit-tracking (brushing/flossing frequency, last visit, symptom matrix) with opinion-scale and rating questions on perceived oral health and dental anxiety, giving clinicians both quantitative and qualitative signal.
  • Includes a barriers-to-care question and insurance/benefit status alongside demographics, helping practices and public health programs triage and prioritize outreach, not just log symptoms.
  • Closes with a clear message that responses are reviewed by care staff, and every response is automatically quality-scored with an auto-generated report for the clinical team — no manual chart review needed.

SurveySparrow

Dental Screening Form Template

A ready-to-use static dental screening form covering standard intake and symptom questions. It's built for quick deployment on SurveySparrow's conversational form platform but relies entirely on fixed question logic. Good for basic intake, but not designed to probe deeper into open-ended symptom reports.

What it does well

  • Fielding-ready template, no build-from-scratch effort needed
  • Conversational form UI likely improves completion rates over a paper form
  • Positioned specifically for healthcare/dental use cases

Where it falls short

  • No adaptive follow-up on reported pain or symptoms — respondents get the same fixed questions regardless of answers
  • No voice AI interview option or guided screen-share task capability
  • No visible automated quality scoring or auto-generated clinician-facing report

Typeform

Dental Screening Form

Typeform offers a polished, conversational-style dental screening template focused on visual design and one-question-at-a-time flow. It's a solid static form for collecting habit and symptom data but does not adapt its questioning based on responses. Best suited to simple intake rather than clinical triage.

What it does well

  • Clean, mobile-friendly conversational form design
  • Easy to customize branding and question wording
  • Fielding-ready template usable immediately

Where it falls short

  • Purely static logic — cannot dynamically interview a respondent who reports pain or discomfort
  • No option for voice-based interviewing or screen-share guided tasks
  • No built-in per-response quality scoring or auto-generated summary report for clinical review

Ready to launch?

Open this template in the editor. Every part is yours to change before the first respondent sees it.

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